Book Review

Risk Management Techniques in Perinatal and Neonatal Practice

N Engl J Med 1997; 336:1265-1266April 24, 1997

Article

Risk Management Techniques in Perinatal and Neonatal Practice
Edited by Steven M. Donn and Charles W. Fisher. Armonk, N.Y., Futura, 1996. 704 pp., illustrated. $115. ISBN: 0-87993-640-1

According to the foreword of this book, there were 75,000 negligence claims in the United States in 1994, for approximately $5 billion. It has been estimated that 80 percent of obstetrician–gynecologists have been sued once for medical malpractice, and 25 percent at least four times. The editors of this book and their multidisciplinary team of coauthors, which includes four attorneys, aim to improve communication and understanding between the medical profession and the legal profession. They argue that by identifying obstetrical and neonatal events as they occur and applying risk-management techniques, litigation may be averted.

The message of this book is that to avoid litigation, care givers need not only to be competent, but also to communicate effectively with their colleagues and show a compassionate and caring attitude toward patients and their families. Documentation should be complete, with words chosen appropriately.

In the most informative and innovative chapters, physicians and lawyers exchange views on perinatal interventions. The chapters that do not use this interactive approach provide no information that is not readily available in standard textbooks on perinatal practice. The information on other important aspects of perinatal medicine, such as causation, epidemiology, pathology, microbiology, and diagnostic testing, is also readily available elsewhere. Several authors make little or no reference to risk management, the topic of the book. On the other hand, the advice on risk management is repetitive. Group B streptococcal infections are addressed twice, in a chapter all their own and in a chapter on neonatal infections.

One shortcoming is that the authors fail to define and discuss risk and risk management in detail at the outset; they only allude to it in the preface and provide a definition in the last chapter. Risk management has been extensively used in the engineering and insurance industries and has been applied more recently to health care practice. The Australian standard, Managing Risk in Procurement: A Handbook (Australian Standard/New Zealand Standard Number 4360. Produced by the Australian Government Publishing Service. Canberra, 1996), defines risk as “a measure of the likelihood and consequence of an occurrence” and risk management as “the systematic application of management policies, procedures and practices to the tasks of identifying, analyzing, evaluating, treating and monitoring risk.” These are more precise definitions than this book offers.

Throughout the book, and even in the chapter on prospective risk management, the authors demonstrate a conservative approach to risk management — that is, how to “adjust systems before an occurrence results in a claim” rather than how to use risk-management techniques to prevent the occurrence in the first place. In my opinion, the approach to a book on risk management in perinatal practice should be different. The objective should be to provide valid information on the use of such techniques to improve outcomes and increase the satisfaction of patients and care givers in a cost-effective manner, rather than primarily to avoid litigation. A proactive approach to the avoidance of risk is likely to reduce the number of claims.

It should be obvious to health care providers, attorneys, and defense lawyers that perinatal practice must be based on scientific evidence. Narrative reviews of the literature such as those in this book are inferior to a systematic approach. Many perinatal interventions addressed in this textbook have been reviewed previously with systematic techniques of overview or meta-analysis. Applying the evidence from such systematic reviews to clinical practice should not only improve patient care, but also form the foundation for successful litigation or defense of claims in the perinatal field. In the next edition, the editors should be encouraged to provide evidence derived from systematic reviews and to have such evidence appraised critically by the legal profession.

Arne Ohlsson, M.D.
University of Toronto, Toronto, ON M5S 1B2, Canada